CA 125 as a screening test for ovarian cancer

Cleaved forms of the urokinase plasminogen activator receptor in plasma have diagnostic potential and predict postoperative survival in patients with ovarian cancer

PURPOSE

To evaluate the plasma level of different forms of soluble urokinase plasminogen activator receptor (suPAR) as discriminators between malignant, borderline, and benign ovarian tumors and as prognostic markers in patients with ovarian cancer.

EXPERIMENTAL DESIGN

The different suPAR forms were measured in preoperative plasma samples obtained from 335 patients with adnexal lesions using three different time-resolved fluoresence assays (TR-FIA): TR-FIA 1 measuring intact suPAR, suPAR(I-III), TR-FIA 2 measuring the total amount of suPAR(I-III) and the cleaved form, suPAR(II-III), and TR-FIA 3 measuring the liberated uPAR(I). Tumors were classified as benign (n = 211), borderline (possibly malignant; n = 30), and well (n = 19), moderately (n = 15), and poorly (n = 60) differentiated malignant.

RESULTS

All uPAR forms as well as CA125 were statistically significant in univariate analysis discriminating between benign, borderline, and invasive tumors. Restricting the analysis of invasive tumors to early stage (I and II) showed similar results. A combination of CA125 and suPAR(I-III) + suPAR(II-III) discriminated between malignant (all stages) and benign tumors [AUC, 0.94; 95% confidence interval (95% CI), 0.90-0.98] as well as borderline and benign tumors (AUC, 0.78; 95% CI, 0.67-0.89). All suPAR forms were markers for poor prognosis in univariate analyses, and high preoperative plasma level of uPAR(I) is an independent predictor of poor prognosis (hazard ratio, 1.84; 95% CI, 1.15-2.95; P = 0.011) in multivariate analyses including age and CA125.

CONCLUSIONS

High concentration of plasma uPAR(I) is an independent preoperative marker of poor prognosis in patients with ovarian cancer. The combination of plasma suPAR(I-III) + suPAR(II-III) and CA125 discriminates between malignant and benign tumors with an AUC of 0.94.

High preoperative plasma concentration of tissue plasminogen activator (tPA) is an independent marker for shorter overall survival in patients with ovarian cancer

OBJECTIVE

The objective was to evaluate the preoperative blood concentration of tissue plasminogen activator (tPA) as a discriminator between malignant and benign ovarian tumors, and as a potential marker of postoperative prognosis in patients with ovarian cancer.

METHODS AND MATERIAL

The concentration of tPA was assayed with ELISA (Imulyse Biopool) in preoperative plasma samples obtained from 111 patients with adnexal lesions. Tumors were classified as benign (n = 25), borderline malignant (n = 11), well-differentiated (G1, n = 22), moderately differentiated (G2, n = 11), and poorly differentiated malignant (G3, n = 42). The median follow-up time of patients with malignant tumors was 5.6 years (range 2.1-13.2 years) and 37 patients died during the follow-up period.

RESULTS

Patients with moderately and poorly differentiated tumors had higher levels of plasma tPA compared to those with well-differentiated tumors (P = 0.004 and P = 0.005). No significant differences in the plasma tPA levels were observed between patients with benign, borderline, and well-differentiated tumors. The tPA levels were not different between stages nor within stage Ia-c. In a multivariate Cox proportional hazards model including stage, grade, age, and plasma tPA dichotomized at the median (> or =9 vs <9 ng/mL), high levels of tPA were significantly associated with shorter survival: HR = 4.4 (95% CI 2.0-9.8, P = 0.0003). In the univariate analyze high levels of tPA showed HR = 4.5 (95% CI 2.1-9.6, P = 0.0003).

CONCLUSIONS

High concentration of plasma tPA was an independent marker for poor prognosis in patients with ovarian cancer in our study. Plasma tPA did, however, not discriminate between benign and malignant adnexal lesions.

Ovarian cancer screening

Ovarian cancer is the fourth commonest cause of cancer deaths in women. Multimodal screening with serum CA125 and transvaginal ultrasonography have been shown to improve survival. However, the results so far do not justify routine screening until the impact of screening on mortality has been assessed in larger randomized trials.

Anxiety/uncertainty reduction as a motivation for interest in prophylactic oophorectomy in women with a family history of ovarian cancer

Most women at familial risk for ovarian cancer must decide about prophylactic oophorectomy without conclusive genotypic information about their risk level. Some women with relatively low-risk profiles seek prophylactic oophorectomy or are recommended the procedure by their physicians, if they appear "cancerphobic." This study investigated the desire to reduce anxiety in relation to other factors associated with interest in prophylactic oophorectomy in a group of women with varying degrees of familial risk for ovarian cancer. Ninety-four women enrolled in an ongoing program for women with a family history of ovarian cancer received personalized risk counseling and were classified as having a sporadic, familial, or putative hereditary pedigree by a genetics counselor. Eligible enrollees were interviewed by telephone about current and future interest in prophylactic oophorectomy, perceived risk of ovarian cancer, severity of cancer anxiety, stress-related ideation, and reasons for and against surgery. Reduction of anxiety/uncertainty was the factor most strongly associated with current interest in prophylactic oophorectomy, independent of objective risk classification, perceived risk, severity of cancer anxiety, intrusive ideation, or other variables. Future interest in prophylactic oophorectomy was predicted by other perceived benefits of surgery. Current, but not future, interest in prophylactic oophorectomy appears motivated in part by seeking immediate relief from anxiety. Interest in prophylactic oophorectomy may fluctuate based on varying exposure to cues that trigger anxiety. Women seeking prophylactic oophorectomy, particularly those with lower-risk family pedigrees, should be offered options for anxiety management as part of informed consent for prophylactic oophorectomy.

Laparoscopic surgery for complex ovarian masses

STUDY OBJECTIVE

To assess the value of laparoscopy in managing complex ovarian masses.

DESIGN

Retrospective, observational analysis (Canadian Task Force classification II-2).

SETTING

University-based, tertiary level center for endoscopic surgery.

PATIENTS

Two hundred eleven consecutive women.

INTERVENTIONS

Laparoscopic surgery including ovary-preserving surgery, salpingo-oophorectomy, adhesiolysis, and pelvic lymphadenectomy.

MEASUREMENTS AND MAIN RESULTS

Patients were selected on the basis of preoperative ultrasound findings. Intraoperative appearance of the tumors as well as results from frozen section examinations were compared with histologic results. Two hundred sixteen pelvic masses were benign. In 10 patients, early ovarian cancer, borderline tumors, tubal cancer, or secondary ovarian, nongynecologic pathology was managed primarily by laparoscopy and confirmed histologically. Three of these 10 women underwent standard radical open surgery within 1 week. The true nature of masses was not recognized at the time of laparoscopy in three patients with malignant findings. Patients with malignant tumors were followed for 5 years.

CONCLUSION

Although most complex ovarian masses can be managed by laparoscopy, the possibility of overlooking malignancy remains, even with frozen section examination. Whether or not laparoscopy compromises clinical outcome compared with laparotomy is not fully understood. Prospective studies to address this important clinical question are urgently needed.

Screening strategies for ovarian cancer

Alternative procedures have been proposed for the detection of early ovarian cancer in asymptomatic women. Transvaginal ultrasonography, with or without colour Doppler imaging and intra-tumoural blood flow analysis, is used as the definitive technique in all current screening programmes. Target populations for clinical trials are recruited on the basis of risk factors for the disease (e.g. age or postmenopausal status, family history of ovarian cancer). Whether or not a participant is scanned may depend on results from the immunoassay of tumour antigens in peripheral serum, or from pedigree analysis. New developments include the use of: (i) intra-tumoural blood velocity as an end-point of colour Doppler imaging, (ii) serial measurements of serum tumour antigens to identify women for ultrasonography, and (iii) tests which detect regionally clustered germ-line BRCA1 mutations. More research is required to assess the beneficial and adverse effects of the new strategies.